Bluebird Care East Suffolk, Great Yarmouth and Lowestoft

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service consistently demonstrated a highly effective learning culture. There was clear evidence that the management team routinely analysed all aspects of the work carried out with people using the service, as part of regular reflective practice, as well as following any incidents or concerns. The management team shared findings and results from their analyses with the workforce and staff embraced ‘learning from’ to help continuously improve outcomes for people using the service.

The management team completed a ‘Risk Analysis Review’ every month. They explained that these provided regular opportunities to identify any emerging trends or patterns, which could then help them to implement appropriate improvement strategies across the service.

We saw from the Risk Analysis Review that concerns, accidents and incidents were dealt with immediately by the management team, with clear investigations into causes, as well as actions and learning to prevent recurrences.

In one case, medication management arrangements were reviewed following a medication-related incident. Appropriate actions were taken to reduce risk, including changes to support arrangements, the introduction of secure medication storage, and revised responsibilities for the management and administration of medicines. These measures helped to ensure medicines were managed safely and in line with assessed needs and also provided assurance and confidence for family members who were concerned about this aspect of care.

In addition, successes and compliments were reviewed and celebrated with staff, which meant that learning from positive experiences could help enhance the lives of more people using the service.

Staff were enthusiastic and spoke positively about the open culture within the service. They said that all incidents were discussed and reviewed and told us, “We discuss what could have been done better by lessons learnt.” And, “We are informed at staff meetings or face to face, then we reflect on what we need to change to prevent things from happening again.”

Staff also told us they embraced opportunities for learning and completing training. A healthcare professional told us about the registered manager and said, “A strong focus on staff learning and development runs through all discussions. [Registered manager] regularly highlights training, qualifications and development opportunities within the organisation to strengthen workforce growth. Overall, [registered manager] demonstrates clear commitment to staff development, recognition and continuous improvement.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had clear systems and processes in place to support people with any transitions regarding care and support. For example, staff met with people prior to providing care to gather detailed information about the person, find out what was most important to them and establish how they wanted to be supported. Staff also liaised with other health and social care professionals involved in people’s care to gather information about their health and wellbeing and support continuity of care.

The service worked hard to ensure that, as much as possible, people were supported by the same care staff, so they could build up positive and trusting relationships with them. People and their representatives made comments such as, “They ensure consistent carers when they can.” And, “I am sure my [relative] is safe, partly because they get the same carers. They know them and also have confidence in them.”

People also told us the service was very responsive and accommodating to people’s changing needs. People’s representatives told us, “I have changed [relative]’s care recently to 2 calls a day. All was done very efficiently and, because they are flexible, it was all very easy. I would recommend them.” And. “[Relative] has been in rehabilitation and is finally coming home, with more care in place. [Relative] is looking forward to seeing all [their] carers again and being back in [their] own home.”

Some people also had health passports, which helped provide important information for emergency services or when people transferred between services, such as going into hospital. A person’s representative told us, “The emergency passports are an excellent resource and provide important information quickly when needed.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe using the service. A person’s representative said, “[Relative] is safe with them. We have never had any problems; I trust them all. They all have a good relationship with [Relative].”

Staff completed training for safeguarding people. They were confident about raising safeguarding concerns and understood the reporting processes. A member of staff told us, “A client notified me that a family member was harming them. I reported it to management, and a safeguarding referral was made.” This showed staff were empowered to act and that concerns were taken seriously.

The service worked in line with local safeguarding procedures. Statutory notifications were also submitted appropriately for safeguarding incidents, which helped demonstrate transparency and compliance with regulatory requirements. Where concerns were identified, investigations were carried out and any learning or improvements required were clearly identified and implemented.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The management team and care staff identified and assessed risks to people’s safety. Clear risk assessments and management plans were available in people’s care records. Care staff told us that people’s care records provided them with detailed information about how to support people safely. Risks were regularly reviewed and risk management plans were adjusted as and when needed.

People explained how staff supported them to stay as safe as possible. For example, a person told us, “I need to be more careful when getting into bed as I could fall, but the carers make sure I am safe.” Another person said, “They wash or shower me and dress me. They look after me in the shower, I feel very safe with them. I would trust [staff] with my life.”

People’s representatives also gave positive examples of how people were supported to stay as safe as possible. A representative told us, “I can tell [staff] are trained to do their job. I can see that from their portal as well. [Relative]’s safety doesn’t concern me at all. [Staff] make sure [relative] is sat up properly when eating, as [they have] a risk of choking.

Another representative explained, “[Relative] has a frame and a walking stick as [they are] at risk of falls. [Staff] have to check [Relative] has [their] pendant on, so if they do fall [relative] can let [staff] know. [Staff] check [Relative]’s frame is close to them, to help with their safer mobility.”

The provider had effective systems and processes to identify risks and hazards in people’s home environments. Environmental risk assessments were completed with people using the service and risk management plans were compiled to help mitigate identified risks as much as possible.

People said they had completed needs assessments and risk assessments when they began using the service. These assessments included health and safety for themselves, as well as staff, within their individual home environments.

Staff also ensured people had access to the equipment they required and this equipment was kept in good working order.

People and their representatives told us that staff were very respectful of their homes and were very health and safety conscious. A person’s representative told us, “Staff always lock the doors and check [Relative]’s fire alarm. They leave the house and [Relative] safe.” A person using the service said, “[Staff member] comes on time and always makes sure the house is tidy before [they] leave; like taking the rubbish out for me.”

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We analysed the data from the provider’s electronic call monitoring system for May 2026 and were assured that care visits were managed well and the system was being used effectively. We saw that 93% of calls had been logged and there was no evidence of any missed calls. We saw that punctuality was excellent, with 96% of calls delivered within 15 minutes of scheduled times and virtually no visits were more than 45 minutes late. We found that 97% of calls had travel time factored in and we did not identify any issues with the service delivery.

Comments from people using the service also supported our findings, with comments such as, “Never any issues with lateness or non-attendance.” And, “No one could be better. Nothing is too much trouble. They don’t rush me at all. They come on time, but they ring me if they are running late. I just couldn’t get better care anywhere.”

People using the service also confirmed that staff stayed for the agreed amount of time and were trained well. People told us, “They always stay the right amount of time; sometimes over.” And, “They are well trained. They sometimes send trainees with the regular carer to learn.”

Staff told us they were happy with their rotas. They said they had sufficient time for travelling between visits, as well as enough time allocated for supporting people. A member of staff told us, “There’s plenty of travel time between calls and I never ever feel rushed or that I have to rush.” Another member of staff said, “The rotas are 2 weeks ahead. I'm always happy with my rota.” A third member of staff stated, “During the visits that I attend, I feel as though the timings are excellent and I do get all my tasks done.”

Staff also confirmed that they completed comprehensive training, were supported very well and had regular ‘spot-checks’ of their work. Staff told us, “I have supervisions regularly. Always asking how I feel, or if there are any concerns regarding myself or any clients. They [Management] ask if I want to do any other training and I have spot checks as well.”

Staff told us there were always enough staff to deliver care and support people safely. A member of staff explained, “I have always felt that client safety is a priority. Double-handed care visits are never carried out by one carer alone. If there are staffing issues, management will step in and cover the call rather than compromise safe care.”

The provider followed safe recruitment practices, to ensure suitable staff were employed. This included checking people’s identity, their eligibility to work in the UK, criminal records checks, obtaining references from previous employers and undertaking a values and competency-based interview process.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff completed training for infection prevention and control and understood their responsibilities. Staff confirmed they had enough personal protective equipment (PPE), which helped reduce the risk and spread of infection. Staff told us, “I always wear my PPE as I know the importance of this.” And, “I always wear full PPE for my visits and I always have enough. The office always has more when I need it.”

People and their relatives confirmed that staff adhered to good infection control procedures. A person told us, “Can’t fault them [staff]. Health and safety, as well as good hygiene, is one of their top priorities.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s care records described the level of support people required with their medicines. We saw medicine administration records (MARs) had been completed correctly, which assured us that people were receiving their medicines as prescribed. The management team also completed regular audits to ensure safe medicines management was consistently adhered to.

Care staff had completed training for the safe management and administration of medicines. Senior staff and management completed regular competency assessments in this area, to ensure staff understood and adhered to their responsibilities.

Care staff ensured people received their medicines as prescribed and this was confirmed by people using the service and their representatives. Staff told us, “I have received medication training, and I feel confident helping people with their medication.” And, “If I make a mistake with medication or I notice that someone else has made a mistake I would contact my manager immediately and, if necessary, I speak to 111 or the client's GP about the mistake. I will then follow their advice. I will record and document everything carefully.”

A person using the service told us, “They get me my medication and make sure I take it. Never had any problems there.” Another person said, “They get my tablets ready for me every morning and evening and they check I’ve taken them.”

People’s representatives told us, “I trust them to give medication correctly. They also wait until the meds have been swallowed.” And, “I am really pleased with Bluebird, they collect [Relative]’s meds and they document everything.” And, “They ensure [Relative] gets their eye drops twice a day. [Relative] always gets their medicine.”